If Atlas shrugs off healthcare, it will be a dark day

Most modern American are familiar with the classic political novel, Atlas Shrugged. Love or hate it, the novel had a great impact on political thinking in the West. If you haven’t read it, or aren’t familiar, one of the fundamental questions author Ayn Rand asks is this: what if the producers and innovators of society simply stopped trying? What if they became tired of contributing and being abused, demonized and taxed for their efforts, and simply withdrew their contributions?

Atlas is straining in medicine as the weight of contemporary healthcare continues to fall upon emergency departments and as increasing numbers of physicians in other fields either retire or escape from call duties. I don’t necessarily say this by way of critique. I understand the perspective of those who have, quite reasonably, made tactical withdrawals from the losing battle.

We face fewer available specialists. Drug shortages are rampant. Psychiatric beds are a rarity as state budgets plummet. Committees and professional societies heap volumes and volumes of new rules on the practitioners of medicine, as if it weren’t difficult enough. And yet, at the end of the day, the answer is typically: go to the emergency room; they’ll sort it all out. And we are full, overwhelmed, understaffed, underfunded and overextended.

So what if we took a cue from Atlas Shrugged? What if, in one grand, unified effort, emergency physicians decided to stop doing their work, if only for a day? Or what if we all found another permanent way to earn our incomes? What if we said ‘no’ to further satisfaction surveys, endless psych holds, innumerable Medicare regulations and pointless JCAHO visits? If we refused to be fined for not washing our hands every five seconds, if we said ’15 minutes to a doctor’ is ridiculous. If we explained that blood cultures didn’t matter for most patients and that we were finished giving thrombolytics for stroke when we felt it was the wrong thing to do? What if rule-makers and fine-givers and policy-writers were stuck, for just one day, sorting through the madness that was born of unfunded mandates and unintended consequences? What if we just said NO!

Well, like that game we all play called ‘what if I won the lottery.’ It’s all academic. That is, an Atlas Shrugged moment would be a very unlikely event. For one thing, we aren’t organized enough. For another, we couldn’t replace our incomes (and therefore pay our debts and bills), that easily … or that quickly. In addition, we generally dislike change and we have a wonderful, awful habit of following orders and doing ‘the right thing.’ It’s what got us into medicine. But it’s also what will keep us there far beyond reasonable levels of endurance.

However, another reason emerges. We feel a sense of duty, a sense of obligation, to the patients who come through our doors. No matter how bizarre or difficult the work, we press on and do it. At all hours of the day and night, we station ourselves between patients and death, between patients and disability (no matter how much some of them want it!) and between patients and suffering.

I realized the dedication of my partners and staff recently, as I watched a drunk ‘patron’ pick up his walking stick and pull it back to hit our security officer, even as a deputy politely said, ‘excuse me,’ pushed his way past everyone and fired a Taser into the stick-wielding gentleman. He dropped fast and was hauled away to the law enforcement center in handcuffs.

I realized it a few months ago when an angry psychiatric patient, who had a ‘sitter’ while he awaited placement, picked up the sitter’s laptop and smashed it through the clear plastic window around the nurses’ station.

My stories are mild compared with some of yours. You face violent gang members while I more often face obnoxious drunk Southerners. Many of you face illegals with drug resistant Tb while I am scalpel wielding warrior facing MRSA abscesses by the bucket. I sort through rattlesnake venom and Xanax overdoses while some of you face designer drugs of no known origin, composition or effect.

Of course, we do it all professionally. We do it the best way we know how, with fewer and fewer resources. We do it with falling reimbursement and increasing regulatory burdens. We do it day and night, holidays and weekends. It lacks the glamor and gloss of sexy doctors on television shows. It falls short of the moral clarity actors, and politicians, seem to bring to modern medicine. It is murky and difficult, even on the best days.

Our ‘office’ is the place of chaos. An administrator once told me, on a day of terrible crowding and dangerous volume, that he couldn’t move patients upstairs to the hallway. His reason was this: ‘Dr. Leap, when people leave the ER, they expect to go to a better place.’ I walked away, unable to speak.

Outside of law enforcement, EMS or the military, what work-places are like this? And who would face such things with regularity even as their reimbursement was cut, their threat of lawsuit ever-present and their every move regulated and watched as if living on parole?

Atlas, at least in medicine, isn’t likely to shrug off his duty. Oddly, we love what we do even as there are days we despise it. But that’s a pretty frightening ‘what if.’ All of the senators and congressmen could walk out tomorrow and we’d experience little more than a sudden burst in economic activity. Most of the attorneys could do the same and our litigation would remain gridlocked…like much of it is already. But some things matter every day of the year. Gas has to be refined and pumped. Cars, buses and airplanes have to move people and material. Electricity, along with water and food, has to be available. And disease and injury need to be treated. And even Atlas needs some relief; needs to make a living, needs to pay his bills. For Atlas, at least in our profession, the ‘honor and glory’ of carrying everything is wearing off. And yet, Atlas endures.

What am I trying to say today? America should be thankful that emergency departments are open, and that they are staffed around the clock by well educated, dedicated professionals who don’t shirk their duties.

And thankful that they so far haven’t shrugged off the enormous weight that daily rests upon their broad shoulders. America should pray that they never do.

If Atlas shrugs off healthcare, it will be a dark day indeed.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

“Outside of law enforcement, EMS or the military, what work-places are like this? And who would face such things with regularity even as their reimbursement was cut, their threat of lawsuit ever-present and their every move regulated and watched as if living on parole?”

Actually, you smug privileged jagoff, MOST work-places are like this. All those patients you only see out of your sense of “noblesse oblige”? Most of them probably have it a HELL of a lot harder than you.

When you’re homeless and BLAMED FOR IT, you can complain. Until then you’re a sanctimonious whiny shit.

Mark Williams

Sanctimonious? You haven’t been there. You haven’t been physically attacked by a patient and told later by administration that if you injure a patient in anything but the most obvious case of self-defence you may be held legally liable for their injuries. Pointing out a broken system isn’t sanctimonious. It’s reality. And just because an MD criticizes, it’s whining? Most providers I know, like me, went into medicine because we wanted to help people, and many of us have found ourselves in a system very different from what we imagined. Physicians like Dr Leap should be applauded for trying to be part of a necessary and inevitable change in the system. Or at the very least listened to with a rational and critical ear.

brian

Who is John Gault?

I’m a PCP physician and I dont think it is hard to believe at ALL that atlas might shrug off healthcare. it has already started as Docs retire early and leave Primary care for specialties… it is only a matter of time for the ER docs and specialist to begin to follow suite as the regulators, auditors, and officials turn their attention to them as there are so few PCP to actually attack any further.

I’m an inteligent and driven person. I am sure that I could replace my income just fine in the business world with MUCH less headache.

why do I stay? i love what I do… but not sure how long that could possibly last.

Perhaps, by using Reid’s wisdom and examples, we (our country) can patch together a more cost effective system where insurance companies will be non-profit, where patient’s will have smart cards containing their medical and insurance histories, where primary care will be rewarded for panel size and outcome measures, etc. T.R. Reid traveled the world to search for the cure. We, as a country, should be embarrassed, that we are by far the most expensive with very mediocre health care outcomes.

southerndoc1

I read the cure. Twice. Condition is worse then ever. What’s the next step?

Why is it that when confronted with some hard truths about the future of medicine, the standard response is: 1) you’re just whining 2) you do a bad job anyway? Interesting analysis.

DavidBehar

The resistance may begin with a boycott list. All lawyers are on it. All doctors collaborating with the enemies of clinical care, including government agencies, are on it. All guideline makers on it for promulgating garbage science.

The doctors may serve as a spear point for a boycott movement by all product and service providers. Let the enemy live in the Stone Age.

After the boycott, violence has full justification in ethics, formal logic, and policy.

DixieAngel_76

First off, I’m not a doctor, I’m a nurse, so please forgive me if I’m intruding, but it seems to me that government meddling in healthcare has been the source of most of what’s wrong with it.

The healh care industry and the insurance companies wanted to to business in an unrestricted manner. They got that along with this ‘bottom ‘line’-Yau can’t turn away emergency patients. There’s you liberal “mandate”. Make money hand over fist, just don’t let folks die in the hallway. You are the safety net. That is your position, your lot in life. I. as a patient had nothing to do with that. The government which I assume you despise, should have done more but it didn’t. It just let business go along as those moneyed interests dictated. More, Doc, not less.

DavidBehar

Tom: You are a rent seeking government employee. You are arguing in favor of your rent, in your economic interest. Therefore, all you arguments are self-dealing. Try to not age.

Rent seeking is a polite term for armed robbery. If you refuse to pay taxes to support parasites and other Democrat government dependent workers, a man with a gun will show up and help you pay. In return you get nothing, except avoidance of getting hurt or going to jail.

I’d also like to say that in 5 years without health insurance I haven’t seen the inside of an ER even once. Although sometimes scary the separation from medical care is quite refreshing. I have some training, worked as a corpsman in the Navy, so I’m well aware of that whole culture and have MD friends. Still, I find it refreshing to have nothing to do with it.

Just because your health maybe releatively good,(or your denial intact) doesn’t mean other people are enjoying the same. I worked in a jail for 10 years and left exhausted and demoralized by the multiple failures and general lack of understanding about the consequenses of our current system. And it is not the only one needing overhauling. Education, Criminal Justice, Mental Health and Health Care Disparity all go hand in hand. It was bad before Wall Street, Big Corporations and Bush raped our country finanacially, that just made it so freaking visible we have to deal with it. Thank God. Stop being the Angry White Guy and look around you, walk a mile, and don’t tell me how bad your life already is. This is way more opinionated than I like to get, but you pushed the one button I have set to trigger finger.

I was merely expressing my personal relief at not dealing with this system. I was NOT defending dr leap.

ninguem

I’ve read Edwin Leap’s writing for years in the emergency medicine magazines.

Always seems to me, to be a caring, pious, thoughful man.

Not that I know him, but read plenty of his essays.

I know I would not put up with what he, or any other ER doc, puts up with every day.

Actually, that’s part of Dr. Leap’s problem. He hasn’t shrugged, but a lot of other doctors have.

I guess I did. I do no more hospital work. Just one example. Whole specialty groups have pulled out of ER’s. When I was doing hospital work (I stopped about 2 years ago), I was admitting a patient when the nurse reminded the ER doc there was no orthopedic coverage.

I butted in……..”what happened?”……figuring there was some mix-up, maybe the doc was sick, maybe the doc on call, just forgot and left town, or some human error. It was my business, in case I admitted a patient who needed an ortho consult that day.

No, not an isolated event, all the orthopedic surgeons in a 350-bed hospital in a big city. They all stopped taking call. There was no benefit to doing it, just pain. They realized the hospital needed them more than the other way around.

So it’s not about “what if Atlas shrugs”, because Atlas is shrugging right now.

ebrose

I quit practicing medicine because of intolerable government interference with the delivery of health care, even before Obamacare. I would encourage any disgruntled physician to do the same if you are able to do so. It will only get worse.

tpy2012

The single payor system is exactly the type of entity that would cause John Gault to find more independently minded Physicians to pull away to his hidden valley. All of the physicians who have become employed by the hospital systems, and large beauracracies, are those who expect the system to provide them with all they want, without the risk of “Rearden Metals.” Many Physicians are pulling back to provide the last bastian of quality care in a small primary care practice. Big system Doc’s have put away their black bags and now utilize the CT scan as their fifth part of taking vitals. Hopefully TPR and BP are still being looked at. I have an appointment with Francisco d’ Aconia.

brian

here, here… and well put.

DixieAngel_76

If I might be permitted to interject, I recently went to a clinic to see a doctor, but was told I could only see an NP. Among other things they tried to tell me that there was no way that I had asthma (another doctor told me I did) because my x-ray didn’t show narrowing of the bronchial tubes. She didn’t even give me a pulse oximetry reading or an incentive spirometry test. I have to say I felt like they had collected my money and they just wanted me to go away and not make a fuss.

It’s a beautiful thing to hear doctors begin questioning, albeit far too late! For those who’ve watched the “Kubler Ross” stage of healthcare implode, it’s quite easy to predict what’s going to happen. I believe we’ve gone through shock, outrage, blame, denial. Some are still stuck, looping again and again through these stages, but some are beginning to shrug. Since things still aren’t fixed and there’s no big picture solution in sight for about 2.5 trillion miles (the same number as our healthcare bill) it seems we’re contemplating bargaining. But the question is, what are we asking for? I believe if we want to answer that question, we first have to understand what’s going on. The system is stuck in a disease paradigm. It is geared to make money from disease. It’s trained doctors to believe that they are the center of a healthcare model, by working backwards from disease. And so, mass confusion has resulted, as well as epidemics of disease, because it’s all we know. It’s all we talk about. We even talk about finding health, by paying a third party $13,500 per capita and rising, to “teach” us how to create a health model that’s actually only a small fraction of that cost. But here’s a thought. What if we ‘shrugged’ the system and created our own system? What if we stood up against a collapsing system, without fear, and brought health practitioners (not just doctors) together directly with patients to teach them how to create a new health model, based in health practice, not end-stage disease practice where they end up in the over-crowded emergency rooms? What if we did that on the last remaining frontier of freedom in this country – – the internet! What if we were proactive as physicians..and not just reactive??http://www.youtube.com/watch?v=6-IOsBOLG0I

brian

wow… never realized KevinMD had collected so many haters…

southerndoc1

It’s one of the major doctor-hating sites on the Web!

BenRush MD

Dr. Leap’s Emergency Dept Crew has much in common with Kipling’s Tommy –

Ayn Rand became what she despised when she was down and out anddying of lung cancer from eing a chain smoker – taking social security and Medicare.

There may not be a cure to our health care costs as no country has a perfect system but we could correct many problems if we had a universal system (all countries in T.R. Reid’s book did).

Switzerland, not in the book, is probably the best model for the US. The Swiss government’s role is to set the rules for insurance companies, physicians and hospitals (in concert with them) and then to monitor all so no one is cheating the other. They are not involved with the administration of the insurance. For-profit insurance for essential services is outlawed. It is mandated for everyone. Insurance is subsidized according to income (and overall the govenrment subsidized more as % of GDP than the US). Choices galore – over 1000 insurance companies within 26 Cantons. Rates are advertized in the newspaper. Choice of HMO (lower cost) or private. Supplemental insurance for such things as private hospital rooms (very expensive) is where the insurance money is made. Administrative costs average 6%. EMR is standardized as it is in most other countries.

Information (payment) between physicians and insurance, and insurance and patients moves fast, It must, as patients pay some amount up front.

Even though Obamacare has soem likenesses to the Swiss system, when fully implemented health care will remain a patchwork quilt. We will never be able to get what is right for our coutry until “we the people” reclaim our government. It is well known the Bigs (corps, other entities) own our politicians. This pheonomenon has bee with us since the beginning – from the southern Bigs who fought against abolition because salvery was, to them and economic necessity, through 1965, so that even with a democratic house, sendate and president, Johnson had to give the AMA (a Big)what they demanded to pass Medicare. All the subsequent fixes to Medicare have only bee poor and costly repairs to the existing patchwork quilt of health care. Before any of you cry foul here, I suggest you read The Transformation of American Medicine – the rise of a sovereign profession and the making of a vast industry – Paul Starr, 1982.

There are two more major human speed bumps to “quality, cost effective universal health care system for the US”. They too involve the Bigs but also “we the people” have to take 50% of the responsibility here. Our SAD (standard American Diet is made to order to result in overeating unhealthy food (as the layers of sugar, fat and sodium) and hence the preponderance of chronic preventable diseases that then eat up our health care dollars (over 60%). Secondly,dying with dignity is not an option in the US. A few compassionate states allow this but in general, the fearmongers have set us backwards allowing the media to entertain (probably for entertainment) one persons focus on something called a “death panel). The Swiiss regards both of these issues important and in need of improvement. First, for the health and quality of life of their population and secondarily to keep health cares costs under control. No heroics, paitent wishes, Euhanasia is accepted for the later and with regard to diet and health they are considering a tax on unhealthy food – their obesity rate is about 9% (the US is 34%. Their health care costs are the highest in the world seond only to the US which is double theirs and without universal coverage.